Alcohol/Substance Abuse
Professionalism (appearance, eye contact, behavior) Explains task, assures confidentiality, obtains consent * Hello my name is [Medical Student] and I'm a first year medical student at [Medical School]. * Can I get your full name and age please? * Mr. Doe, today my attending physician has asked me to take your history. * This will require me asking a few questions about your health, do I have your permission? * I just want to remind you that anything we discuss will be confidential. * Is there anything you need before we begin? Begins with open ended questions and transitions * What brings you in today? Establishes alcohol intake: amount, type, duration * How much alcohol do you drink per week? * What kind of alcohol do you drink? * How long have you been drinking? * Mr. Doe, I want to ask you a few questions about your drinking habits, is that okay with you? Screens for abuse using CAGE questions * Have you ever felt you needed to cut down on your drinking? * Have people annoyed you by criticizing your drinking? * Have you ever felt guilty about drinking? * Have you ever felt you needed a drink first thing in the morning to steady your nerves or to get rid of a hangover? * Mr. Doe, I'm asking to ask you a few more personal questions about your drinking so I can get a better picture of what's going on; is that okay? Screens for addiction i.e. asks about negative consequences such as health issues, loss of work, DUI, relationship issues etc. * Have you ever had any health related issues due to drinking? * Have you ever had any problems with work due to drinking? * Have you ever had a DUI? * Have you had any relationship issues due to drinking? Asks about depression * Is there anything in your life that you're depressed about? * Is there anything in your life that's causing you stress? Asks about illicit/recreational drug use * Do you take any other recreational drug such as cocaine or marijuana? Asks about family history of alcohol abuse * Is there anyone in your family that have trouble with alcohol? * Thank you for your honesty Mr. Doe. Demonstrates empathy, offers counselling -- help available * Mr. Doe, I'm sorry you haven't been feeling well but I think you'll feel better sooner if you stop drinking. * Have you ever ever thought about quitting alcohol? * I just want to let you know that we have counselling and resources to help you quit alcohol whenever you're ready. * That's all for your history, thank you for coming in. * Do you have any questions? Summary presentation and communication skills * Example ** We have a 50 year african male that has signs of jaundice. ** The patient has been drinking 3 glasses of Vodka a day for the past 2 years and has positive CAGE test. ** The patient continues to drink despite negative consequences such as DUIs. ** He has a family history of alcohol abuse. Knowledge question